Promise of Nursing Regional Faculty Fellowship Application

Note: You cannot save your work and come back to the application at a later time. Data entered will not be saved.

Required Attachments

The items below must be uploaded at the end of the application. Be sure all items are ready to go before beginning this application.

Curriculum Vitae (CV)

Current Academic Transcript

Dean Certification

Letter of Reference

Financial Aid Certification

Copy of RN License

Alien Registration Card (if applicable)

Section 1: Student Information

Full Name
*

First Name Last Name

E-mail
*

Mailing Address
*

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

Permanent Address
*

Same as address above Different than address above

Enter Permanent Address
*

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

Phone
*

Work Phone
*

Student ID#
*

Social Security # last four digits ONLY
*

Are you a US Citizen or an Alien with U.S. Permanent Resident Status?
*

Yes I am a US Citizen Yes I am a US Permanent Resident (please submit copy of Alien Registration Card) No I am not a US Citizen or US Permanent Resident

In order to apply for the Promise of Nursing Regional Faculty Fellowship, the applicant must be a US Citizen or an Alien with U.S. Permanent Resident Status. Unfortunately, you are not eligible to apply for the fellowship.

Gender
*

Male Female

Date of Birth
*

Marital Status
*

Single Married Divorced Widowed

Ethnicity Optional

Caucasian Black or African American American Indian or Alaska Native Asian Hispanic or Latino Native Hawaiian or other Pacific Islander Mixed Race

Mixed Race (please indicate)

How did you hear about the Promise of Nursing Regional Faculty Fellowship Program?
*

0/100

Section 2: Academic Information

College/University
*

Program
*

School Address
*

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

Please indicate the Promise of Nursing Region that you are eligible for:
*

Diversity refers to all the ways in which we are similar and/or different. In the space below, in 200 words or less, please describe how you meet this definitition of diversity as an individual and how this will help to impact the nursing profession.

Question on diversity for Pennsylvania applicants only

Name of Dean/Director/Chair
*

Dean Phone
*

Name of Faculty Advisor
*

Faculty Advisor Phone
*

Type of Program
*

Master's Degree Program Doctoral Degree Program

Note: Students in RN to BSN or RN to MSN programs are not eligible to apply.

What type of degree will you receive?
*

MA MEd MSN PhD EdD DNP

Program Start Date
*

Expected Date of Graduation
*

Type of School
*

Public Private Not-For-Profit Private - For Profit

Are you enrolled in an online program?
*

Yes No

Current Enrollment Status
*

Full Time Part Time

Current Number of Credits
*

Indicate the number of credits you plan to take during the following semesters:

Fall 2017
*

Winter 2017
*

Spring 2018
*

Summer 2018
*

Educational History:

Please list all nursing school and college preparation to date. Note: after filling out the fields below, be sure to click "Save Line / Add Row" to save that line in this form.

Section 3: Employment Information

Are you currently employed as a faculty member in a nursing program?
*

Yes No

School
*

Name of School

City

State / Province

Postal / Zip Code

Country

Employment
*

Full Time Part Time Adjunct Joint Appointment

Do you receive tuition reimbursement/ waiver where you are employed
*

Yes No

Please indicate type:
*

Tuition Reimbursement Tuition Waiver

How many credits per year are covered by the tuition reimbursement/ waiver?
*

credits/year

Indicate your current employment information:

Current Job Title
*

Employer
*

City
*

State
*

Zip
*

Contact Person
*

Contact Phone
*

Do you receive tuition reimbursement from your current employer?
*

Yes No

How many credits of tution reimbursement do you receive per year?
*

In the space below please answer the following question. If the degree you are pursuing is not in a nursing education program, please indicate how the program will prepare you for the role of nurse educator?

Degree Preparation

0/200

In the space below indicate the area of research/thesis project that you are planning to or are currrently engaged in and why?

Research/ Thesis Project

0/200

Section 4: Student Expenses and Resources

List projected expenses and resources for the 2017-18 academic year, including summer school (if applicable).Note: Review all expenses and resources carefully and include all anticipated income and reasonable expenses that you/ your family will incur during the 2017-18 academic year.

Sources of Income for 2017-2018

Annual Salary (Self)
*

Annual Salary (Spouse)
*

Military/VA/GI Benefits
*

Social Security Benefits
*

Student Loans
*

Scholarship / Fellowship / Grants
*

Other

Other (List)

Total Resources

This field is auto calculated.

Expenses for 2017-2018 Academic Year

Tuition & Academic Fees
*

Books
*

Rent / Mortgage / Utilities
*

Food
*

Transportation
*

Medical / Dental
*

Other

Other (List)

Total Expenses

This field is auto calculated.

Indicate the number of dependents you report on your personal income tax:
*

Are you currently serving in the Military?
*

Yes No

Which branch?
*

Are there any other family members attending college during the 2017-18 academic year?
*

Yes No

How many other family members are attending college?
*

Have you previously receved a PON Fellowship?
*

Yes No

When did you receive a PON Fellowship?
*

In the space below, list Fellowships/Scholarships you have received in the past year and if they are approved for the 2017-18 academic year. Be sure to click "add/save" to save each line you enter.

Click "add/save" to list Fellowships and Scholarships

Section 5: Personal Statement

In the space below, describe your education, research, and career goals and how the PON Fellowship will you help you achieve those goals. Include any special circumstances that you would like the selection committee to be aware of. Your statement must not exceed 300 words.

Personal Statement

0/300

Section 6: Certification and Agreement

Please read this section carefully before agreeing to the terms and conditions of the PON Fellowship.

I hereby request consideration and believe myself to be eligible to apply for a Promise of Nursing Regional Faculty Fellowship administered by the FNSNA. I have completed all necessary paperwork and certify that all information supplied on this application is complete and correct. I understand that: falsification of information on my application, transcripts or other attachments will disqualify my application; failure to follow all instructions to complete the application will render my application incomplete; and that all FNSNA Board of Trustees decisions are final.

I understand that the completed application and associated documents become FNSNA property. By signing this agreement, permission is granted to FNSNA to request and/or verify information in the application and in my tuition account from the Dean/Director and/or the Financial Administrator of the graduate program.

If I am a recipient of a PON Fellowship administered by the FNSNA and funds are awarded to me, by signing this agreement I also agree to the following terms:

1. Notify the FNSNA of any change in my address, phone number, and email address.

2. Fellowship funds will only be used towards tuition, academic fees and books for the Fall 2017, Winter 2017, Spring 2018, and Summer 2018 semesters in the school that I currently attend. This Fellowship will not be used to pay any other charge or expense I may incur while I am in graduate school.

3. To enroll as a part time (minimum of 6 credits) or full time student pursuing a graduate degree preparing me for the nurse educator role.

4. Notify FNSNA if my career goals change and I am no longer committed to preparation for the nurse educator role and to return the full amount of the PON Fellowship to the FNSNA.

5. Fellowship funds will only be released to the school, specifically to the Office of Financial Aid or Bursar. The check is made payable to the school towards my tuition account.

6. To notify the FNSNA of any change in my enrollment status or program status.

7. If I transfer to another program before the tuition is paid, the total Fellowship amount must be returned to the FNSNA.

8. If I transfer to another school that is eligible to receive Promise of Nursing Fellowship funds, I understand that I must submit a written request along with enrollment verification to the FNSNA to request that any remaining funds be applied to tuition at the new school.

9. If funds remain after tuition and academic fees are paid, the total amount remaining must be returned to the FNSNA. Remaining funds may not be used for the following academic year.

10. I grant the FNSNA permission to request information from my school about my tuition account and enrollment status.

11. If I withdraw from the program BEFORE tuition is paid, all funds are to be returned to the FNSNA. If I withdraw from the program AFTER tuition is paid, all funds are to be returned to FNSNA.

12. That this application and all attachments/enclosures become the property of the FNSNA.

I have read the above information thoroughly and certifiy that if I am awarded a PON Fellowship administered by the FNSNA, I agree to the terms and conditions of the PON Fellowship outlined above.

Agreement (please check)
*

I agree to the terms and conditions of the PON Fellowship outlined above.

Required Attachments

Please upload the following documents to your application.

Curriculum Vitae (CV)
*

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Current Academic Transcript
*

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Dean Certification
*

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Letter of Reference
*

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Financial Aid Certification
*

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Copy of current RN license
*

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Alien Registration Card (If Applicable)

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Application Check List

Please check that you have completed the following items:

Please Check

I have completed all required sections of the application. I have attached my Curriculum Vitae. I have attached a copy of my current academic transcript. I have attached a completed Dean/Director Certification. I have completed my personal statement. I have read and agree to the terms of the PON Fellowship. I have attached one letter of reference. I have attached a completedFinancial Aid Certification. I have attached a copy of my RN license. I have attached a copy of my alien registration card, if applicable

The FNSNA suggests printing a copy of the applicaiton for your records.

Click on the "SUBMIT" button below to submit your completed application to the FNSNA. By clicking this button, you acknowledge that you cannot edit any information contained in this application once it has been submitted.